Endoscopic treatment of difficult choledocholithiasis

Common bile duct stones can be treated with normal endoscopic techniques. Where stones cannot be removed due to their size or number or due to stenosis of the common bile duct, a plastic stent can be inserted, enabling rapid drainage of bile. At the three-month check-up complete removal of the stones was found in 41 (85.4%) of the 48 patients with difficult choledocholithiasis. In the remaining 7 patients (14.6%), the stent in any case resulted in clinical improvement. A permanent stent was necessary in 4 patients, enabling safe drainage with no complications. The use of endoscopy for stent placement was effective in all our cases of difficult coledocholithiasis without any complications.

Small bowel adenocarcinoma. Two case reports

Introduction. Small bowel adenocarcinoma is a rare tumor, with a still not well studied tumorigenesis process, and non-specific symptoms that cause a delay in the diagnosis and consequently a worst outcome for the patient. Videocapsule endoscopy (VCE) and double-balloon enteroscopy (DBE) have revolutionized the diagnosis and management of patients with small bowel diseases. Surgery is the treatment of choice when feasible, while the chemotherapeutic approach is still not well standardized. Case reports. Two cases in 2 months (two women 52 and 72-yr-old) of primary bowel adenocarcinoma is reported. The site of the tumor was in jejunum, instead of the most common site in duodenum. The patients underwent DBE with biopsy and ink mark. Laparoscopic-assisted bowel segmental resection was performed. The pathologic diagnosis was primary jejunum adenocarcinoma. No post-operative mortality or significant morbidities were noted. Conclusion. The combination of DBE and laparocopic-assisted bowel surgery represents an ideal diagnostic and therapeutic method.

Anastomotic strictures in colorectal surgery: treatment with endoscopic balloon dilation

The incidence of anastomotic stricture following colorectal surgery has increased in recent years. This complication is observed in 2-5% of all operated patients and is probably due to the greater number of low anastomoses performed with surgical staplers. We observed 31 patients with postoperative stricture, arising from one to nine months post-surgery. All patients had been treated for colorectal cancer and underwent endoscopy either during routine follow-up or for symptoms of stenosis. In 16 patients (group A) the stricture diameter was less than 4 mm and the patients had symptoms attributable to partial bowel obstruction. In the remaining 15 patients (group B), who had difficult bowel movements, the stricture diameter ranged from 4 to 8 mm. All patients were treated with endoscopic dilation using achalasia balloons. The results were considered good when the post-dilation anastomosis diameter achieved was at least 13 mm, fair when it was 9-12 mm and poor when it was less than 9 mm. The short term results (3 weeks) were good in 27 patients (87.2%), fair in 3 patients (9.6%), and poor in 1 patient (3.2%). After several unsuccessful dilations, the latter was treated by surgery. Follow-up at 3-4 months of the remaining 30 patients revealed good results in 20 (66.6%), fair in 6 (20%), and poor in 4 (13.3%). In 1 of these 4 patients, cancer recurrence was observed and a new surgical resection was performed. In 2 patients a self–expandable metal stent was inserted for 4-6 weeks, with satisfactory results. In 1 patient a biodegradable polydioxanone stent was inserted with good results after 6 months. Follow-up at 3-4 months showed good results in 25 patients. After 38 months, cancer recurrence in the area of the anastomosis was observed in 1 patient, who was treated surgically. Endoscopic dilatation should be considered the first therapeutic approach in case of anastomotic strictures, as it is immediately effective, repeatable, and does not preclude surgery if this should become necessary. .

Polyp of the cecum. Laparoscopic-assisted polypectomy

The Authors discuss on a laparoscopic-assisted approach for excision of a sessile villous adenomatous polyp of the cecum, unresectable by endoscopy. Because of the large implant of the polyp, endoscopic polypectomy was considered at high risk and a surgical laparoscopic procedure was scheduled for removal of the lesion. After right colon mobilization, an intraoperative endoscopy confirmed the location of th polyp in the posterior wall of the cecum, closed to the ileo-cecal valve. A small 10 cm laparotomy, through which the cecum was pulled out the abdominal cavity, was performed. Then, a minimal colotomy along the intestinal taenia was carried out to allow a safe and complete excision of the polyp. This laparoscopic approach differs from the other laparoscopic-assisted methods reported in the Literature since it provides at the same time the postoperative advantages associated with minimal access surgery and a safe oncological removal of the polyp with low risks of complications. .

Pancreatic pseudocyst: case report and short literature review

We report a case of pancreatic pseudocyst secondary to acute necrotizing pancreatitis treated with open cystogastrostomy. Following a literature review, we stress the enormous benefits offered by modern diagnostic techniques, and especially imaging techniques, for the diagnosis and monitoring of this disease. Treatment should be delayed for at least six weeks, following which the drainage by open surgery offers the best results and lowest morbidity and mortality, followed by laparoscopy and endoscopy, indicated in particular cases and in patients where open surgery is contraindicated.